Saturday, August 15, 2015

Regret

If you talk with people experiencing anxiety and depression for any length of time, one the the common recurring themes is regret. Regret is one of those complex psychological dimensions that spills over into everyday life. It is a significant disappointment somewhere on the trajectory of life associated with negative emotions. It is such a common experience that friends and family members will sometime talk about their regrets, or the regrets of another friend or family member. It is a universal human experience that can make you sad or anxious and also amplify those emotions when they are part of a more phasic mood disturbance.

In the above classic movie scene a young Marlon Brando playing Terry Malloy, a dock worker who is dealing with corruption and crime in that setting. He had been a promising boxer until his brother Charley in this scene (played by Rod Steiger) convinced him to throw a fight in order to favor Charley's boss at the time. Charley is also trying to dissuade Terry from testifying against that same boss in this scene. Those are parts of a more complex plot, but it contains all of the detail that is relevant as Terry and his brother discuss the incident in this famous scene. Terry seems to be expressing regret at two levels - one for throwing the fight and the effect it had on his reputation but more importantly for having an older brother who does not look out for his best interests and does not treat him well. Charley seems to be treating him well in this scene only as a form of bribery. He is offering him a paying job only to buy his silence.

People tend to regret a lot of things in the course of a lifetime - lost relationships, past behavior, missed opportunities, repetitive patterns of behavior that they don't seem to be able to break out of, and in some case entire periods of their life. Common examples from the late teens to young adulthood include missed opportunities in relationships, school, and work. It is very common to hear people complaining that they regret not applying themselves in school. In some cases they regret choosing a particular career path and worry about whether it is too late to change. There are myriad regrets possible just considering the family structure and the emotional reactions and expectations that people have of one another. It can be combined with blame as in: "I wish you would have forced me to keep up those piano lessons." At times people predict what might lead to regret in the future. A common prediction is: "Your grandparents are not going to be around forever. You might regret not going on this visit to see them." In this era of social media, there are always posts about what you will regret on your death bed. Apparently it won't be not spending enough time at work. When I was a junior in high school, one of my friends predicted that I would regret not going to the prom. In the decades since, I have had very few thoughts about high school and none on that dance.

One of the many questions that I find myself pondering in my down time is; "What is the best conceptualization of regret?' What is the best way to make sense of it? What is the best way to adapt to it? Does it make sense to think about getting over it? At one point in my early 20s, I took a harsh approach to some emotional thought patterns that could be troublesome. My credo became "No guilt, no shame." I started to spread the word. I encouraged people to be proactive which is really the best approach. If you make decisions on a daily basis that will not result in guilt or shame, what could be better? No regret would be a welcomed by product. Of course there were sacrifices along the way - spontaneity and risk taking being a couple of good examples. You run the risk of being a "stick in the mud". There is also the very real issue that you can just be wrong and despite your best intentions there are regrets along the way.

Regret is one of those concepts that seems to crossover from psychiatry to literature and English professors may do better job of analyzing and appreciating it. In Moby Dick, Melville introduces Captain Ahab's family in order to point out the contrast between an obsessive, all consuming pursuit of the white whale and time spent away from his family. After casting a single tear of regret into the sea, a tear described as in the following passage:

"From beneath his slouched hat Ahab dropped a tear into the sea; nor did all the Pacific contain such wealth as that one wee drop."

Ahab launches into this soliloquy that is an ode to regret: "Oh, Starbuck! it is a mild, mild wind, and a mild looking sky. On such a day—very much such a sweetness as this—I struck my first whale—a boy-harpooneer of eighteen! Forty—forty—forty years ago!—ago! Forty years of continual whaling! forty years of privation, and peril, and storm-time! forty years on the pitiless sea! for forty years has Ahab forsaken the peaceful land, for forty years to make war on the horrors of the deep! Aye and yes, Starbuck, out of those forty years I have not spent three ashore. When I think of this life I have led; the desolation of solitude it has been; the masoned, walled-town of a Captain's exclusiveness, which admits but small entrance to any sympathy from the green country without—oh, weariness! heaviness! Guinea-coast slavery of solitary command!—when I think of all this; only half-suspected, not so keenly known to me before—and how for forty years I have fed upon dry salted fare—fit emblem of the dry nourishment of my soil!—when the poorest landsman has had fresh fruit to his daily hand, and broken the world's fresh bread to my mouldy crusts—away, whole oceans away, from that young girl-wife I wedded past fifty, and sailed for Cape Horn the next day, leaving but one dent in my marriage pillow—wife? wife?—rather a widow with her husband alive! Aye, I widowed that poor girl when I married her, Starbuck; and then, the madness, the frenzy, the boiling blood and the smoking brow, with which, for a thousand lowerings old Ahab has furiously, foamingly chased his prey—more a demon than a man!—aye, aye! what a forty years' fool—fool—old fool, has old Ahab been!......." (Chapter 132).

His chief-mate Starbuck tries to talk him into ending the pursuit, but we all know how that turns out. Even world class regret does not necessarily lead to self correction. Similar statements cut across clinical and non-clinical settings. I don't consider regret to be a symptom of any psychiatric disorder per se, but it will typically make things worse and in some cases be an unexpected point of focus. What might be useful points for discussion? A standard supportive approach would look at how human consciousness operates. Whether you are a boy harpooner of 18 or a prize fighter in your early 20's, you are likely to make decisions at those times in your life that will not be the same decisions that you make 5 or 10 or 20 years later. Eighteen year olds are energetic, eager to prove themselves, at their physical peak, and to a large degree see themselves as being invincible. They are bound to make decisions much different than a 60 year who has battled life for 40 years and is left feeling spiritually withered. Not being the same person at 60 as you were at 18, is not necessarily that intuitive in areas of life apart from the physical ones. I think it illustrates that the situation remains dynamic and there is no reason to expect that different decisions can't occur. In modern society, the decision to retire is a key decision that activates some of these thought patterns and associated regrets.

Physicians are professionals with some of the highest degree of regret. There is the phenomenon of physician burnout fueled largely by the fact that they have limited control over what happens in clinical settings and that the people with more control don't know anything about medicine. Many of the burnout surveys have to do with regret about going into medicine. But there are also the inevitable mistakes in patient care. I heard a neurosurgeon describe some of his regrets on public radio including a case where he tried to resect an additional amount of tumor that resulted in the patient being in a persistent vegetative state. I was personally in a discussion of a transnasal resection of a growth hormone secreting pituitary adenoma that was wrapped around the internal carotid artery. The discussant was a neurosurgeon who had probably done more of this procedure by far than any other surgeon in the world. That discussion went something like this: "This is the tumor and this is the artery (pointing to areas on an MRI coronal view of the pituitary gland and sphenoid sinus). I am going to try to remove as much of the tumor as possible. If I accidentally nick the carotid artery in this area, there is nothing that can be done about it. That complication happens and I know good neurosurgeons who have had that happen to them. I can assure you I will remove only as much tumor as possible. I will remove only as much as I would remove if you were one of my family members." Since I heard that conversation, now 6 years ago, I have come to realize that it was more than just an informed consent discussion of the worst possible complications. It was also a way that this surgeon had learned to set limits on himself and the drive to completely remove a tumor, even at a point where the risk may be increasing exponentially. I have seen good physicians who approached medicine as a science, who were not able to adapt to the inevitable mistakes or adverse outcomes. Many ended up paralyzed with regret and needing to take time away from the field. Some left for good. I don't think we do a very good job with medical students and trainees in helping them develop a realistic view of the field. A view that might temper them against the inevitable regrets.

As psychiatrists, we all need the vocabulary for discussing regret with our patients, because it is one of those things that crops up and takes over an appointment scheduled for another purpose. We suddenly find ourselves in a supportive or psychodynamic or cognitive-behavioral or mindfulness mode dealing with the crisis. Everything we had planned to do in that session, including assessing the patient's progress with their primary problem has gone out the window. More importantly regret is part of life and not an error in thought or emotion. Normalizing that experience will go a long way toward helping the person in crisis.

George Dawson, MD, DFAPA

Refs:

Herman Melville. Moby-Dick or the Whale. Project Gutenberg EBook. Originally published in 1851.

Attribution:

The graphic of the original cover of Moby Dick is from Wikimedia Commons with the attribution line. It is in the public domain:

By The original uploader was Chick Bowen at English Wikipedia (Transferred from en.wikipedia to Commons.) [Public domain or Public domain], via Wikimedia Commons.